Clinical Connection / December 2018

Happy Holidays – Video Vignette

The Staff of AZH Wound & Vascular Center would like to wish you a Healthy and Happy Holiday Season.  We hope you enjoy this festive video greeting! We look forward to serving you and your patients in 2019.

Case of the Month

It Take a Team Approach to Provide Limb Salvage:   This 65 year old male, with PMH positive for DM, CAD, HTN and PAD, presented to AZH Wound & Vascular Centers with a necrotizing infection of his Right Foot.  He was evaluated and then admitted for surgical debridement and antibiotics under the skillful care of an IPN Hospitalist. Soon after discharge, he underwent a vascular evaluation which revealed significant BLE arterial compromise.  Successful endovascular intervention by Dr. Siddique was performed as an outpatient at the AZH Vascular Center. Hyperbaric Oxygen Therapy and advanced wound care was then initiated at AZH Wound and Hyperbaric Center. In approximately 12 weeks after the onset of this limb threatening infection, the patient was fitted with custom orthotics, ambulated without difficulty and returned to work.  An integrated and a coordinated team approach provides optimal clinical outcomes with severe limb threatening conditions.

Services & Technologies

Hyperbaric Oxygen Therapy

Definition:  Hyperbaric oxygen therapy (HBOT) is defined as treatment during which a patient inhales 100% oxygen inside a pressure vessel capable of the delivery of pressures exceeding 1.4 atmospheres absolute (ATA).  In the outpatient setting, HBOT is typically administered in a single patient monoplace chamber. For routine conditions, HBOT therapy is typically administered at 2.0 ATA for 90 minutes of oxygen breathing. Hyperbaric therapy has been used worldwide for more than 50 years in the treatment of many chronic non-healing wounds and ulcers.  The safety record of HBOT in this country is excellent and the technology has become a vital part of the growth of comprehensive wound care programs across the nation.

Basic Oxygen Physiology:  Oxygen is the third most common element and it comprises approximately 21 percent of the air we breathe.    Once in the blood, oxygen is preferentially bound to the hemoglobin molecules on the red blood cells, and at sea level the average person has essentially 100% saturation of the hemoglobin molecules. However the plasma can also carry dissolved oxygen, and in fact this system provides a great reserve in oxygen carrying-capacity. Under normal atmospheric pressure, the average person has about 0.3 volume per cent of dissolved oxygen in their plasma. Oxygenated blood flows to distal tissues and under normal physiologic conditions the oxygen is offloaded to provide the energy substrates to fuel tissue metabolism.  Oxygen delivery can be negatively impacted by conditions that inhibit uncoupling of oxyhemoglobin (such as tissue acidosis) or in conditions that prevent adequate tissue perfusion (i.e. peripheral arterial disease, edema, and conditions causing vessel sludging or trauma). In regards to wound healing, normal tissue oxygenation is critical to collagen synthesis, epithelialization, angiogenesis and bacterial killing.                                                                                                                                                                                  

Hyperbaric Oxygen Physiology:  The oxygen carrying-capacity of the plasma is immense, and this reserve capacity is exactly the target of the supra-physiologic oxygen levels provided by HBOT.  A patient breathing 100 percent oxygen at 3 ATA will have an enormous increase in the amount of oxygen physically dissolved in the plasma (6.9 volumes per cent) compared to the volume of oxygen dissolved at 1 ATA (0.3 volume per cent). The brain only uses 6.1 volumes percent per pass, so the brain is fully oxygenated from oxygen dissolved in the plasma. In fact, plasma pO2 values well in excess of 1500-1800 mmHg are routinely achieved in hyperbaric patients. In this setting the hemoglobin never desaturates, and thus hemoglobin plays a minimal role in the transport of oxygen. Tissue oxygen partial pressures can reach 250 to 300 mmHg, far above the normal 30 to 40 mmHg when breathing air at one atmosphere. This 18-20 fold rise in dissolved oxygen establishes a tremendous gradient between the plasma and the peripheral tissues.  It is this steep oxygen gradient that stimulates and initiates neoangiogenesis. In addition to the supraphysiologic oxygen gradient, there is a significant increase in oxygen diffusion distance from the tissue capillary beds (247 microns). Given that the intercapillary distance in living tissue is less than 247 microns, it should be apparent that the four-fold increase in the oxygen diffusion radius provided by HBOT is an effective countermeasure against any tissue hypoxia that may be present. In addition, the supraphysiologic oxygen levels seen in hyperbaric patients can also reduce tissue edema through a compensatory vasoconstriction effect caused by an auto-regulatory mechanism inherent to the vasculature. Thus hyperbaric oxygen has a multifactorial mode of action: increased oxygen levels in the plasma available to diffuse farther into hypoxic tissues, while reducing tissue edema through compensatory vasoconstriction.

Cellular Effects of HBOT:  In addition to hyper oxygenation, it is well documented that HBOT can induce angiogenesis and neovascularization in hypoxic tissues. Molecular oxygen is universally considered to be simply a consumable substrate to support our metabolism. Many non-healing wounds do not heal because they are chronically infected or hypoxic. Because oxygen levels below 40 mmHg do not allow leukocytes to kill bacteria, raising the tissue levels much higher than normal improves white cell bactericidal function. At oxygen partial pressures of 150 mmHg, white cell killing ability is doubled or tripled beyond that found in even normally oxygenated leukocytes.  HBOT has been demonstrated to have a positive impact on limiting the deleterious effects of reperfusion injury. It blocks guanylate cyclase, the trigger molecule for beta-2-integrin that forms the leukocyte adhesion molecule. Thus, following ischemia or sepsis, leukocytes do not stick to the capillary walls to block circulation when the patient is treated early with HBOT. HBOT prevents leukocytes from adhering to the capillary wall, then boring through it into the tissues surrounding the vessel and releasing the super oxide anion, proteinases and elastase that liquefy tissue following crush injury and other forms of ischemia.

HBOT Indications:  Some of the most common conditions treated with HBOT include the diabetic foot ulcer (DFU), chronic refractory osteomyelitis (CROM), and both osteoradionecrosis (ORN) and soft-tissue radionecrosis (STRN). Less common indications for HBOT include necrotizing soft tissue infections, decompression sickness (DCS) and carbon monoxide (CO) poisoning.  HBOT is the treatment of choice for DCS and CO poisoning, and the timely treatment of both of these conditions can prevent many of the long-term neurologic sequelae often seen in patients not receiving hyperbaric oxygen. Promising results are being observed in the treatment of patient with acute concussion syndrome and traumatic brain injury.

AZH Hyperbaric Center operates 4 monoplace hyperbaric chambers and is Joint Commission (JCAHO) Accredited.

Super Star

Jeffrey A. Niezgoda, MD, FACHM, MAPWCA, CHWS:  Dr. Jeffrey Niezgoda is the President & Chief Medical Officer of AZH Centers.  Advancing the Zenith of Healthcare is a novel company dedicated to excellence in wound, vascular and regenerative clinical services.  Dr. Niezgoda is also the founder of Web CME, an international educational company with a mission to provide wound care and hyperbaric education over the internet.  Over the past 10 years, WebCME has trained over five thousand healthcare providers. For 16 years (1998-2013) Dr. Niezgoda held the position of Medical Director of the Center for Comprehensive Wound Care and Hyperbaric Oxygen Therapy at St. Luke’s Medical Center in Milwaukee Wisconsin and served as the President and Chief Medical Officer of Hyperbaric & Wound Care Associates.  During this tenure, Dr. Niezgoda opened the first Comprehensive Wound Care Clinic in the Midwest and was the first to introduce the concept of Advanced Wound Care in Milwaukee.

He is the Vice President of the American Professional Wound Care Association and the Immediate Past President of the American College of Hyperbaric Medicine.  He serves as an honorary member of the Board of Directors of The American Board of Wound Healing and as member of the Board of Examiners for the creation of the Physician’s Certification Examination in Wound Care, the Physician’s Hyperbaric Certification Examination, and the Certified Hyperbaric and Wound care Specialist Examination.  He has participated in multiple Expert Consensus Panels and has appeared before Medicare and Medicaid Services and the Food and Drug Administration to provide expert opinion in wound care and hyperbaric medicine. Dr. Niezgoda has lectured extensively both on hyperbaric oxygen therapy and advanced wound care, presenting over 1000 podium and poster presentations at national and international conferences. He is a life member of the National Eagle Scout Association and the founder and President-Emeritus of the Association for Bladder Exstrophy Children.

Dr. Niezgoda holds an M.D. from the Uniformed Services University of the Health Sciences, F. Edward Herbert School of Medicine, Bethesda, Maryland, and is a 1981 graduate of U.S. Air Force Academy.  He is married to Kathleen (who is working by his side at AZH as an Advanced Practice Nurse Practitioner). They have 4 children Geoffrey (28), Jonathan (22), Laura (16) and Margaret (5).

IPN Insider

ACO Distributes Profit Sharing:  This is the second of a series of videos in which the State of the (IPN) Union is presented by the IPN CEO, Mike Repka.   Mike discusses another successful year of IPN participation in the ACO Medicare Shared Savings Program. He encourages all IPN physicians to work together to decrease the cost associated with referrals to hospital based programs, physicians and services.  By keeping ACO patients within the IPN physician referral network cost of care can be controlled and the savings realized will benefit our patients, the ACO and member physicians.

2019-01-15T15:22:21+00:00December 19th, 2018|